WASHINGTON, D.C. - A beneficiary's claim for wrongful denial of disability benefits under the Employee Retirement Income Security Act does not accrue for limitations purposes until the plan's internal benefits resolution process has been exhausted, notwithstanding a plan provision providing that the limitations period commences before the plan has resolved the claim for benefits, a plan participant told the U.S. Supreme Court in oral arguments on Oct. 15 (Julie Heimeshoff v. Hartford Life & Accident Insurance Co., et al., No. 12-729, U.S. Sup.).
LOS ANGELES - A California appeals court in an Oct. 11 unpublished opinion affirmed that the City of Long Beach did not have to arbitrate a health care reimbursement dispute because it was not a party to the contract that contained the disputed arbitration provision (Promise Hospital of East Los Angeles v. CIGNA Corp., et al., No. B243126, Calif. App., 2nd Dist., Div. 8).
COLUMBUS, Ga. - A Georgia federal judge on Oct. 9 declined to dismiss a qui tam action against a doctor accused of submitting false claims to Medicare and Medicaid, saying the plaintiff's allegations were stated with sufficient particularity to put the defendant on notice of the claims asserted against him (Richard Barker, on behalf of the United States of America and the State of Georgia v. Columbus Regional Healthcare System Inc., et al., No. 12-108, M.D. Ga.; 2013 U.S. Dist. LEXIS 145695).
Several federal courts on Oct. 4 granted motions by the government to stay proceedings in challenges to the Patient Protection and Affordable Care Act (PPACA) during the current lapse in appropriations due to the partial government shutdown that began Oct. 1. The government began filing motions to stay the proceedings on Oct. 1 in courts across the country, with courts beginning to issue rulings on Oct. 2.
NEWARK, N.J. - A New Jersey federal judge on Oct.7 remanded a health care reimbursement suit to state court, finding that the defendant failed to show that federal preemption existed under the Employee Retirement Income Security Act (Medwell v. CIGNA Healthcare of New Jersey Inc., No. 13-3998, D. N.J.; 2013 U.S. Dist. LEXIS 144577).
DENVER - A 10th Circuit U.S. Court of Appeals panel on Oct. 3 affirmed that a lower court correctly granted a preliminary injunction to keep the federal government from enforcing a mandate contained in the Patient Protection and Affordable Care Act (PPACA) that requires most employers to provide birth control coverage as part of their employee health plans against a heating, ventilation and air conditioning company. The court based its opinion on its recent decision in Hobby Lobby Store Inc.'s challenge to the mandate (William Newland, et al. v. Kathleen Sebelius, in her official capacity as Secretary of the United States Department of Health and Human Services, et al., No. 12-1123; 10th Cir.).
HOUSTON - A Texas federal judge on Oct. 4 denied a plaintiff's motion to amend judgment against it and to allow it to file a third amended complaint in a reimbursement dispute, saying that amendment would be futile (Electrostim Medical Services Inc. v. Health Care Services Corp., No11-2745, S.D. Texas; 2013 U.S. Dist. LEXIS 144266).
OKLAHOMA CITY - Because certain prescribed cancer drugs were determined to be not "medically necessary" or accepted by the medical community at large, an Oklahoma federal judge on Oct. 1 concluded that an insurer did not breach its contract or act in bad faith by denying a policyholder's coverage claims for those drugs (Dana J. Delluomo v. American Medical Security Life Insurance Co., No. 5:11-cv-01337, W.D. Okla.; 2013 U.S. Dist. LEXIS 141502).
SAN FRANCISCO - The Ninth Circuit U.S. Court of Appeals ruled Sept. 30 in an unpublished opinion that although a health plan participant was not entitled to benefits based on the insurer's delay in processing her claim, the participant might be entitled to attorney fees under the Employee Retirement Income Security Act if the filing of the instant lawsuit caused the insurer to pay the claim (Selina Bryant v. Cigna Healthcare of California, Inc., et al., No. 11-57249, 9th Cir.; 2013 U.S. App. LEXIS 19966).
JACKSON, Miss. - A federal judge in Mississippi on Sept. 30 denied a motion to dismiss a qui tam action filed by three former employees of SouthernCare Inc., a hospice provider in Mississippi, saying the claims of fraud met the False Claims Act (FCA) requirement that whistle-blowers are the original source of the fraud allegations (United States of America, ex rel. Deborah Woods, et al., v. SouthernCare Inc., No. 3:09cv00313, S.D. Miss., Jackson Div.; 2013 U.S. Dist. LEXIS 141524).
ATLANTA - A federal judge in Georgia on Sept. 27 granted a request for injunctive relief by two severely disabled children against David A. Cook, as commissioner of the Georgia Department of Community Health (GDCH), ordering the state department to provide the plaintiffs' requested increase of skilled home nursing care under the Medicaid program (Marketric Hunter, et al. v. David A. Cook, Comissioner of the Georgia Department of Community Health, No. 1:08cv2930, N.D. Ga., Atlanta Div.; 2013 U.S. Dist. LEXIS 139963).
ANNAPOLIS, Md. - Maryland's highest court on Sept. 30 held that a health maintenance organization (HMO) member who has been billed by a health care provider for a covered service does not have an implied private cause of action under Maryland Code, Health-General Article, Section 19-710(p), but is not precluded from bringing an action under the state's Consumer Protection Act (David Scull, et al. v. Groover, Christie & Merritt, No. 71, Md. App.; 2013 Md. LEXIS 609).
CAMDEN, N.J. - A federal judge in New Jersey on Sept. 26 denied class certification of claims that United Healthcare, as the claims administrator for thousands of health insurance plans, violated the Employee Retirement Income Security Act by using a method for estimating what Medicare would have paid for services that resulted in underpayment for insureds under the plans' coordination-of-benefits provisions (Mark Lipstein, et al. v. UnitedHealth Group, et al., No. 11-1185, D. N.J.; 2013 U.S. Dist. LEXIS 138045).
PORTLAND, Maine - A Maine federal judge on Sept. 30 dismissed without prejudice a potential class action suit against the secretary of Health and Human Services, which alleges that a recent amendment to Maine's Medicaid plan that reduced or terminated Medicaid benefits does not comply with the "maintenance of effort" requirement of the Patient Protection and Affordable Care Act (PPACA), saying it would be improper to proceed in the state's absence (Louis Bourgoin, et al. v. Kathleen Sebelius, No. 13-55, D. Maine; 2013 U.S. Dist. LEXIS 140599).
WASHINGTON, D.C. - The U.S. Senate will meet at 2 p.m. Sept. 30 - 10 hours before a government shutdown deadline - to decide what to do after the Republican-controlled House approved legislation yesterday imposing a one-year delay of the Patient Protection and Affordable Care Act (PPACA) and repealing a tax on medical devices in budget negotiations.
DENVER - A federal judge in the U.S. District Court for the District of Colorado on Sept. 24 affirmed a U.S. Department of Health and Human Services (DHHS) Medicare Appeals Council ruling finding that coverage for dental surgery is unavailable under Medicare. The judge explained that surgery to repair a beneficiary's mandible to improve her overall health did not fall under the exceptions to Medicare's prohibition for coverage for dental services under Medicare Part B (Dixie Born v. Kathleen Sebelius, Secretary of Health and Human Services, No. 11cv002507, D. Colo.; 2013 U.S. Dist. LEXIS 136396).
LAFAYETTE, La. - A Louisiana federal judge on Sept. 23 adopted the findings of a magistrate judge in dismissing a wrongful denial of health benefits case, but allowed the plaintiff time to amend her complaint to assert violations of the Employee Retirement Income Security Act (Amelia Simon v. Express Scripts Inc., et al., No. 13-187, W.D. La.; 2013 U.S. Dist. LEXIS 136090).
NEWARK, N.J. - A New Jersey federal judge on Sept. 24 declined to dismiss a fraudulent health care billing suit, finding that the plaintiff health insurer properly supported its claims against the health care provider (Connecticut General Life Insurance Co. v. Roseland Ambulatory, No. 12-5941, D. N.J.; 2013 U.S. Dist. LEXIS 136374).
TOPEKA, Kan. - A Kansas federal judge on Sept. 20 denied a defendant's motion for acquittal or, in the alternative, a new trial following her conviction for 12 counts of health care benefit fraud and conspiracy to commit health care fraud in violation of Medicaid laws (United States of America v. Caela M. White-Kinchion, No. 11-40023, D. Kan.; 2013 U.S. Dist. LEXIS 134516).
MADISON, Wis. - A Wisconsin federal judge on Sept. 20 declined to dismiss a complaint alleging that a health insurer and companies hired to advertise its policies on television committed fraud and bad faith in their advertising practices, allowed the plaintiffs to amend their complaint and declined to grant class action status to the case (Harry R. Wiedenbeck, et al. v. Cinergy Health Inc., et al., No. 12-508, W.D. Wis.; 2013 U.S. Dist. LEXIS 134672).
LEXINGTON, Ky. - A Kentucky federal judge on Sept. 18 denied the Kentucky Cabinet for Health and Family Service's request to vacate and dissolve a partial finding of contempt issued against the cabinet for failing to properly process requests by Medicaid patients to transfer from one in-network Coventry Health and Life Insurance Co. facility to another facility in light of Coventry's impending termination of its provider contract with Appalachian Regional Healthcare Inc. and ARH Breckenridge Health Services Inc. (collectively, ARH) Appalachian Regional Healthcare, et al. v. Coventry Health and Life Insurance Co., et al., No. 12-114, E.D. Ky.; 2013 U.S. Dist. LEXIS 133126).
BOSTON - A Massachusetts federal judge on Sept. 18 dismissed a health care provider's suit against a network facilitator for violations of the Telephone Consumer Protection Act (TCPA) and the Junk Fax Prevention Act (JFPA), saying that the fax in question was not an advertisement (Physicians Healthsource Inc. v. Multiplan Services Corp., No. 12-11693, D. Mass.; 2013 U.S. Dist. LEXIS 133397).
LOS ANGELES - A California federal judge on Sept. 18 remanded a breach of health care contract suit to state court, saying that the Employee Retirement Income Security Act did not preempt the claims (Port Medical Wellness Inc. v. Connecticut General Life Insurance Co., et al., No. 13-3604, C. D. Calif.; 2013 U.S. Dist. LEXIS 134612).
SAN FRANCISCO - The Ninth Circuit U.S. Court of Appeals on Sept. 17 denied a motion for rehearing and rehearing en banc filed by the California Department of Health Services, thus reaffirming its ruling that California legislation eliminating coverage for certain health care services conflicted with the Medicaid Act and, therefore, was invalid (California Association of Rural Health Clinics, et al. v. Toby Douglas, et al., Nos. 10-17574, 10-17622, 9th Cir.).
WASHINGTON, D.C. - A federal judge in the District of Columbia on Sept. 16 held that the federal government's decision to not intervene in two qui tam actions filed under the U.S. False Claims Act was within its discretion and cannot be reviewed by the court, concluding that the federal agencies may choose not to intervene in a qui tam action even when evidence suggested fraud under the Medicare statute has been committed (Michael L. Davis v. U.S. Department of Health and Human Services, et al., No. 12-1246, D. D.C.; 2013 U.S. Dist. LEXIS 131796).